Cardiology Coding Alert

Remember: Consider a signature log or attestation statement if the provider’s signature is illegible.

If you’ve ever puzzled over Medicare’s signature guidelines, then fret no more. National Government Services (NGS) provider outreach and education consultants Gail O’Leary and Lori Langevin recently hosted a webinar that can help answer some of your most burning questions about this topic.

Read on to see how much you know about Medicare’s signature guidelines.

Check These Signature Criteria for Validity

Question 1: How do I know if a signature is valid?

Answer 1: A valid signature will meet the following requirements, according to Langevin:

• The ordering physician authenticated the services that he provided or ordered.
• The signature is legible. (If the signature is illegible, you can submit a signature log or attestation statement).
• The signature is handwritten, electronic, or stamped (a special exception).

Don’t miss: Using a stamped signature is a very special exception. CMS permits use of a rubber stamp for a signature in accordance with the Rehabilitation Act of 1973, according to O’Leary.

“Stamped signatures are only permitted in the case of an author with a physical disability who can provide proof of an inability to sign due to a disability,” Langevin explains.

Discover Definition of Handwritten Signature

Question 2: What is Medicare’s definition of a handwritten signature?

Answer 2: A handwritten signature is “a mark or sign by the ordering or prescribing physician or NPP on a document signifying knowledge, approval, acceptance, or obligation,” per the Complying With Medicare Signature Requirements Fact Sheet.

Signature Not Legible? Do This

Question 3: My physician’s signature is not legible. What can I do about this?

Answer 3: You can send a signature log or attestation statement to support the identity of an illegible signature, according to Langevin.

Signature log defined: “A signature log is a typed listing of the provider or providers identifying their name with a corresponding handwritten signature,” O’Leary says.

You must also include the credentials associated with the initials or the illegible signature, O’Leary adds.

Don’t miss: You may include the signature log on the same page where the initial or illegible signature is located or in a separate document, O’Leary says. Just make sure that the signature log is a part of the patient’s medical record.

Attestation statement: You can also submit an attestation statement if the provider’s signature is illegible. For Medicare to consider an attestation statement valid, the author of the medical record entry must sign and date the statement, according to O’Leary. The statement must also include the appropriate patient information.

Follow These Rules for Electronic Signatures

Question 4: What guidelines must we follow for electronic signatures?

Answer 4: If your providers use electronic signatures, you must make sure they meet the following certain criteria, according to Langevin:

• Rule 1: The systems and software your office uses must be protected against modification.
• Rule 2: Your administrative safeguards should follow standards and laws.
• Rule 3: Teach your office that whoever’s name in on the alternate signature method and the provider are taking responsibility that the attested info in the medical record is true.
• Rule 4: Include a copy of your office’s electronic signature protocol procedure.

Handle Amendments and Corrections Like This

Question 5: I have a situation where an entry related to a service the physician provided was not properly documented, so we need to amend the paper medical record. How do we best go about doing this?

Answer 5: First of all, make sure that your practice heeds certain recordkeeping principles, says Langevin. Any document you submit to your MAC should “clearly and permanently identify any amendment, correction, or delayed entry as such.”

You also want to make sure that you clearly mark the date and the author of any amendment, correction, or delayed entry, as well as the original date of the entry you are correcting.

And, you should clearly identify the original content of the record, without deletion. This is very important, Langevin says. You should never delete anything from a medical record. 

In the case of a paper medical record, you can perform a correction by using a single line to strike through the content. Make sure the original content is still legible. And, the person who makes the alteration to the record should sign and date it.